PELVIC ORGAN PROLAPSE & CONSERVATIVE

MANAGEMENT

MODERATOR : DR. ACHLA BATRA

PRESENTERS : DR. SABEENA

DR. OSHAL
DR. MONISHA
 CONTENTS

• DEFINITION
• ANATOMY
• RISK FACTORS
• CLASSIFICATION OF PELVIC ORGAN PROLAPSE
• EXAMINATION
• SIGNS AND SYMPTOMS
• CONSERVATIVE MANAGEMENT
• CASE DISCUSSION
 DEFINITION

Pelvic organ prolapse

Descent of pelvic organs, anterior vaginal compartment (cystocele , urethrocele ), apical compartment
( Uterus, vault or cuff scar after hysterectomy ) and/or posterior compartment (enterocele and
rectocele).

POP affects > 50% of all women over 50 years of age

• Anterior compartment prolapse - Hernia of anterior vaginal wall associated with
descent of the bladder (cystocele) and/ or urethra (urethrocele)

• Posterior compartment prolapse -Hernia of the posterior vaginal segment

associated with descent of the rectum (rectocele)

• Enterocele – Hernia of the intestines to or through the vaginal wall.

• Apical compartment prolapse – Descent of the apex of the vagina into the lower
vagina, to the hymen, or beyond the vaginal introitus . The apex can be either the
uterus and cervix, cervix alone, or vaginal vault

• Uterine procidentia – Descent of uterus with complete eversion of vagina.

Cystocele Rectocele

Enterocele
ANATOMY

Supports of pelvic organs

1. Connective tissue of pelvis
2. Pelvic diaphragm
Levator Ani- Pubococcygeus
- Iliococcygeus
Coccygeus/ ischiococcygeus
3. Perineal membrane
MUSCLES OF THE FEMALE PELVIC FLOOR

Muscles Origin Insertion

Pubococcygeus Post aspect of Anococcygeal

inferior pubic raphe
rami

Iliococcygeus Arcus tendinous Anococcygeal

levator ani raphe

Ischiococcygeu Sacrospinous Anococcygeal

s ligament & raphe
ischial spine
 ENDOPELVIC FASCIA
CONNECTIVE TISSUE OF PELVIS IS COLLECTIVELY KNOWN AS ENDOPELVIC FASCIA

Endopelvic fascia

Parietal pelvic Visceral pelvic

Deep endopelvic fascia fascia
connective tissue

1.Obturator Fascia
Fascia covering: Vagina,
2. Levator Ani Fascia
Uterus, Bladder, Rectum
3. Coccygeous Fascia
(Sacrospinous Ligament)
X Fallopian Tube, Ovaries
4.Pyriformis Fascia
 COMPONENTS OF DEEP PELVIC
CONNECTIVE TISSUE
Deep pelvic connective tissue

Pericervical ring/
supravaginal
Ligaments (6) Septa (2)
septum

• Uterosacral ligaments
(Rectal Pillars) • Pubocervical
• Cardinal Ligaments/ Septum/ Fascia
Mackenrodt’s • Rectovaginal
• Pubocervical Septum/ Fascia
Ligaments (Bladder
Pillars)
Arcus tendineus Levator Ani (ATLA)
Thickenings of parietal fascia of pelvic sidewalls (Ischial Spine to Pubic Tubercle)
Arcus tendineus Fascia Pelvis/ White Line (ATFP)
Thickening of parietal fascia of the bellies of iliococcygeous, inferior to ATLA. These form lateral
attachments of Pubocervical Fascia and Proximal Rectovaginal Fascia.
Arcus tendineous fascia Rectovaginalis (ATFRV)- Fascial thickening posteriorly to white line.
Serves as lateral support
to Distal Rectovaginal Fascia.
 DELANCEY LEVELS OF VAGINAL SUPPORT

Level 1

Level 2

Level 3

Level 3
Level 2 Perineal body, perineal
Level1
Endopelvic fascia connections to arcus membrane and superficial &
Cardinal ligaments & Uterosacral ligaments
tendineus fascia pelvis (ATFP) deep perineal muscles.
 BOAT IN DOCK ANALOGY

• The boat corresponds to the uterus/vagina

• The ropes to the ligaments/fascias
• The water to the supportive pelvic floor muscle.
• The ropes act to hold the ship in the center of its berth.
• The support system will not function if the water level falls; the ropes holding the boat will be stressed and
eventually break
Loss of level 1 support Loss of level II support Loss of level III support

• Uterovaginal prolapse • Cystocele • Urethral hypermobility

• Post hysterectomy vault prolapse • Rectocele • Distal rectocele
• Enterocele • Lax perineum
 RISK FACTORS OF PELVIC ORGAN PROLAPSE
• OBSTETRICS RELATED
Multiparity (4 fold after 1st & 8 fold increase after 2nd birth*)
Rapid succession of pregnancies
Unattended deliveries
Delivery of big baby
Prolonged second stage of labour
Instrumental delivery
Lack of rest in puerperium
Lack of any pelvic exercises

*Epidemiology of genital prolapse: observations from the Oxford Family

Planning Association Study
• Menopause
Aging
Hypoestrogenism
• Chronically increased intra abdominal pressure
Obesity ( 50% increased risk of POP )
Constipation
COPD
• Repeated heavy weight lifting
• Undernutrition
• Following hysterectomy
• Genetic factors
Race (Hispanic ,white > blacks, Asian)
Connective tissue disorders ( Marfans , Ehler Danlos syndrome) Type 1/3 collagen
• Spina bifida
 POTENTIAL RISK FACTORS FOR POP

Predispose Incite Promote Decompensate

Genetic Pregnancy and delivery Obesity Aging

Smoking Menopause

Race: Surgery such as Pulmonary disease Myopahty

White> African- hysterectomy (chronic coughing) Neuropathy
American for prolapse

Myopathy Constipation (chronic Debilitation

straining)

Neuropathy Occupational Medication

(Heavy Lifting)
 CLASSIFICATION OF PELVIC ORGAN PROLAPSE

• Jeffcoate’s
• Malpa’s
• Shaw’s
• Baden walker
• POP-Q
• Simplified POP-Q
 SHAWS CLASSIFICATION OF PELVIC ORGAN PROLAPSE
• Anterior vaginal wall : Upper two-third – Cystocele

Lower one-third - Urethrocele

• Posterior vaginal wall : Upper one-third—Enterocele (pouch of Douglas hernia)

Lower two-third—Rectocele
• Uterine descent
• - Descent of the cervix into the vagina
• - Descent of the cervix up to the introitus
• - Descent of the cervix outside the introitus
• -Procidentia-All of the uterus outside the introitus
 THE BADEN-WALKER HALFWAY SYSTEM

The extent of prolapse is recorded using a number 0 to 4 at each of the 6 defined sites
in the vagina.

There are 2 sites each on the anterior , superior and posterior wall of vagina.--

ANTERIOR – URETHRA & VESICAL

SUPERIOR - UTERUS & CUL DE SAC

POSTERIOR- RECTAL & PERINEAL

THE BADEN-WALKER HALFWAY SYSTEM CONT..

0 – Normal position for each respective site

1 – Descent halfway to the hymen
2 – Descent to the hymen
3 – Descent halfway past the hymen
4 – Maximum possible descent for each site
 POP-QUANTIFICATION

Why ???
• Proven to have interobserver and intraobserver reliability
• The POPQ system is the POP classification system of choice of the ICS, AUGS, and SGS.
• Intraoperative POPQ measurements correlate well with preoperative findings
• Objective, site-specific, quantitatively measuring various points creating a topographic map of vagina
• ALL MEASUREMENTS : CENTIMETERS
• Uses a fixed reference point – hymenal remnants, called point zero (0)
• Positive (+) values distal to hymen
• Negative (-) values proximal to hymen
PHYSICAL EXAMINATION TECHNIQUE

• Position of the patient

• Empty bladder
• Appropriate vaginal speculum
• Method of quantitative measurement
• Measurements in full straining
• Traction should cause no further descent
• Subject should confirm size of prolapse
• Standing straining confirms extent of prolapse
GRID SYSTEM USED FOR CHARTING PELVIC
ORGAN PROLAPSE ( POP-Q)
TOTAL VAGINAL LENGTH (TVL)

• Greatest depth of
vagina
• Done in reduced
position
POINT Aa

• Anatomically defined fixed point

• Midline of anterior vaginal wall 3cm proximal to
external urethral meatus
• Limit: -3 cm to +3 cm
• Corresponds to urethro-vesical crease
POINT Ba
• Dynamic / Variable point
• Most dependent position of
rest of vaginal wall
• (between Aa and vaginal cuff)
• Value -3 cm in absence of
prolapse
• Limit is -3 to + Tvl
 POINT C

• Most distal edge of the cervix or

leading edge of the vaginal cuff
(hysterectomy scar)
 POINT D

• Posterior fornix or pouch of

douglas (POD)

• Represents the level of

uterosacral ligament
attachment to the posterior
cervix

• NO CERVIX= NO D
POINT Ap

• Anatomically defined fixed point

• Midline of posterior vaginal wall

3cm proximal to hymen

• Limit: -3 cm to +3 cm
POINT Bp

• Dynamic / Variable point

• Most dependant portion of rest of the

vaginal wall. ( between Ap and vaginal
cuff)

• Value -3 cm in absence of prolapse

• Limit is -3 to + Tvl
 GENITAL HIATUS

• Middle of external urethral meatus

to mid point of posterior hymen
 PERINEAL BODY

• Posterior margin of genital

hiatus to mid anal point
 STAGES OF PELVIC ORGAN PROLAPSE
STAGE 0 No prolapse is demonstrated
Points Aa,Ap,Ba,Bp all are at -3 cm, and point C or D is between TVL and - (TVL-2
cm)
STAGE 1 The most distal portion of prolapse is > 1cm above the level of hymen

STAGE 2 The most distal portion of prolapse is ≤ 1cm proximal or distal to plane of hymen

STAGE 3 The most distal portion of prolapse > 1 cm distal to plane of hymen but no farther than 2
cm less than the TVL

STAGE 4 Complete to nearly complete eversion of the vagina. The most distal portion of prolapse
protrudes to ≥ (TVL-2 cm)
SIMPLIFIED POP-Q

• Less cumbersome
• Carried out similar to standard POPQ with half speculum placed in vagina.
• Measures only 4 points (Ba, Bp, C, D)
• All in straining, no measuring devices required
• Staging does not include stage 0
STAGING OF SIMPLIFIED POP-Q

• Stage 1 - Prolapse where given point remains at least 1 cm above the hymenal remnants.
• Stage 2 - Prolapse where the given point descends upto Introitus (1cm above or below
hymen)
• Stage 3 - Prolapse where the given point descends >1cm past the hymenal remnants but
doesn't represent complete vaginal vault eversion or procidentia.
• Stage 4 - Complete vaginal vault eversion or procidentia
 EXAMINATION

General Physical Examination (Nutrition status, BMI)

e/o tuft of hair in sacral region – s/o spina bifida, predisposes to prolapse

Per Abdominal Examination (hernial sites, any mass/free fluid)

Local Examination

• Dorsal supine position with knee, thigh flexed

• If prolapse could not be examined completely with Valsalva manoeuvre, other position are
standing ,lithotomy, squatting or sims.
EXAMINATION OF EXTERNAL GENITALIA
Look for vulvar atrophy or presence of any lesions/rashes/ulcers
Introitus – lax or not
EXAMINATION OF PERINEUM
Length of perineal body, any old healed perineal tear
Intact perineum- posterior vaginal wall not visible without separating the labia minora
Old healed perineal tears – lower post. Vaginal wall visibile
• Changes in Vaginal Mucosa
Thickened and Dry Pigmentary Changes
Decubitus ulcer -Benign and is present on the dependant part.
Due to venous stasis and tissue anoxia.
Treated by - keeping the prolapse reduced, which will restore circulation and help in healing. Prolapse can be
kept in reduced position by packing
Infection- Severe infection resulting adhesions may cause protuding mass irreducible
• Changes in cervix
Hypertrophic elongation of both supravaginal and vaginal part
NEUROLOGICAL EXAMINATION OF SACRAL REFLEXES
Bulbocavernosus Reflex – On stroking lateral side of clitoris, contraction of bulbocavernosus muscle on both sides
indicates normal sacral pathway
Anal Wink Reflex— On stroking Anus, elicitation of contraction of anus indicates intact anal sphincter innervation
Elliciting Stress incontinence -leakage of urine on coughing should
be noted.
“Occult or hidden” stress incontinence is revealed in reduced state of
prolapse. This otherwise is not demonstrated due to urethral kinking
or direct compressive effect.
Patient is asked to void urine and then proceed with examination of
prolapse.
 ANTERIOR COMPARTMENT EXAMINATION
• Retracting posterior vaginal wall and Cervix by sims speculum-visualisation of anterior vaginal wall
after maximal straining.

• Identify three transverse sulcus namely submeatal sulcus, transverse, bladder sulcus.

• Bulging of the anterior wall indicating Cystocele and urethrocele to be noted.

• Look for vaginal rugosities, which correlate with pattern of fascial breaks.

• Support lateral sulci with ring forceps,

Midline bulge -- Central Defect

Blunting/descent of lateral sulci – Lateral defect

MIDLINE DEFECT LATERAL WALL DEFECT
 APICAL COMPARTMENT EXAMINATION

• Retracting anterior and posterior vaginal wall with separate sims speculum,
visualisation of apical compartment after maximal straining.

• Look for hypertrophy of cervix, congestion, edema ,decubitus ulcer.

• Note the degree of descent of cervix.

 POSTERIOR COMPARTMENT EXAMINATION

• Retracting anterior vaginal wall and cervix by sims speculum- visualisation of

posterior vaginal wall, while slowly withdrawing the posterior speculum during
valsalva maneuver.

• Bulging of lower part is rectocele.

• After retracting rectocele – bulging of upper part then enterocele.
PALPATION
Protruding mass is grasped at introitus between thumb and fingers. If fundus below
the grip—procidentia
BIMANUAL EXAMINATION
After reducing the prolapse, size of uterus, elongation of supravaginal portion of
cervix and condition of adnexa are assessed.
RECTOVAGINAL EXAMINATION
Posterior wall defects examined and rectovaginal septum palpated for breaks and
thickness.
RECTAL EXAMINATION
Rectocele and enterocele are differentiated: Tip of examining finger bulges through
defect in Rectocele, while finger cannot be pushed through enterocele
ASSESSMENT OF LEVATOR STRENGTH
Introduce index finger 2-3 cm inside hymen at 4o’ clock and 8 o’clock position. Tone and strength of levator ani
assessed by Oxford Scoring.

GRADE RESPONSE

0 No discernible muscle contraction

1 A flicker under the finger

2 A weak contraction or increase in tension without any discernible lift or squeeze

3 A moderate contraction with partial lifting of posterior vaginal wall and squeezing of the finger

4 Good contraction causing elevation of posterior vaginal wall against resistance and indrawing of perineum

5 Strong contraction of pelvic floor against resistance

 DIFFERENTIAL DIAGNOSIS
• Uterine inversion
Cx os not visible, cx rim felt all around the mass and fundus of uterus not felt on bimanual examination
Uterine sound cannot be negotiated.
• Garntners cyst
Well defined margins and is nonreducible. Overlying vaginal mucosa is stretched out with loss of rugosities.
• Pedunculated myoma
Peduncle of myoma can be felt through cx. Uterine fundus can be felt on bimanual examination. Uterine sound can
be negotiated by the side of myoma.
• Vulval cyst or tumour
• Cysts of anterior vaginal wall
• Urethral diverticula
• Congenital elongation of cervix
• Cervical fibroid polyp
PELVIC ORGAN PROLAPSE

• SYMPTOMS
• QUESTIONNAIRES
• CONSERVATIVE MANAGEMENT
 PELVIC FLOOR TRAINING
 PESSARY
SYMPTOMS OF PELVIC ORGAN PROLAPSE
Vaginal dryness
PELVIC FLOOR DISTRESS INVENTORY
Scale:
0 = no answer
1= not at all
2 = somewhat
3 = moderately
4 = quite a bit

Scale score : Obtain the mean value of all of the answered items within a scale
(possible value 0 to 4) and then multiply by 25 to obtain the scale score (range 0
to 100). Missing items are dealt with by using the mean from answered items
only.

Summary score : score of the three scales are added to obtain a summary score
Range (0-300)

The higher the score the greater the perceived impact that pelvic floor dysfunction
has on a patients life
All of the items use the following response scale:
0 = Not at all;
1= somewhat;
2= moderately;
3 = quite a bit
SCALE SCORE: Obtain the mean value for all of the answered items (possible
value 0 – 3)
multiply by (100/3) to obtain the scale score (range 0-100).
Missing items are dealt with by using the mean from answered items only.
PFIQ-7 Summary Score: Add the scores from the 3 scales together to obtain the
summary score (range 0-300).
MANAGEMENT OF UTERINE PROLAPSE

Evaluation
• History
• Examination
• Investigation
• Discussion with patient
• Decision of treatment modality
INVESTIGATIONS

• Urine analysis
• High vaginal swab in cases of vaginitis
• PAC investigations if surgical treatment is required
• USG to r/o pelvic mass and hydronephrosis
• Xray
• ECG
INVESTIGATIONS

If there are urinary or bowel symptoms consider the following:

• Post-void residual urine volume testing .
• Urodynamic investigations.
• Renal ultrasound scan
• Fecal Incontinence : endoanal USG, occult blood, fecalanalysis, endoscopy
INVESTIGATION

• Role of perineal ultrasound

• • can identify levator ani defects
• • can identify Sphincter defects
• Dynamic MRI (dMRI)
• • differentiates between rectocele and enterocoele
• • where the presence of enterocoele is suspected but not certain on physical examination .
• No standardised criteria for use of this imaging modality .
MANAGEMENT OF UTERINE PROLAPSE

• Goal of treatment
• -Alleviate symptoms
• -Restore anatomical structure
• -Restore/Preserve sexual function

• Choice of treatment depends on

• -Symptoms severity
• -Prolapse severity
• -Fertility desire
• Desire to retain uterus
 CONSERVATIVE MANAGEMENT

1. General lifestyle changes

 Good nutrition
 Weight reduction
 Avoid constipation and chronic cough
 Smoking cessation

2. Pelvic floor muscle training and biofeedback

3. Vaginal pessary
 PELVIC ORGAN SUPPORT

• Both levator muscle and connective tissue are important for keeping pelvic organs in
place and preventing POP
 PELVIC FLOOR MUSCLE TRAINING

• Aims at strengthening the pelvic floor - levator ani muscles

• Pelvic muscle floor exercise may limit the progression of mild prolapse and related symptoms ,
• However a lower response rate is seen with prolapse extending beyond the introitus.
• PFME is suitable for mild to moderate POP but not for high-grade POP (POP-Q stage III and IV).

Isotonic contractions
• A woman is asked to squeeze and hold contracted levator ani muscles
• Aim is to achieve a sustained contraction of 10 seconds and 3 sets throughout the day of 10-15
contractions each
• Duration and number of sustained contraction to be increased progressively.

Isometric contractions
• Quick contractions followed by relaxation of levator ani are practiced .
• Helpful in urge urinary incontinence.
Dr. Arnold Henry Kegel was an
American gynaecologist who invented the
Kegel perineometer and Kegel exercises as
non-surgical treatment of urinary
incontinence from perineal muscle weakness
and/or laxity.
 BIOFEEDBACK

• Biofeedback for pelvic floor muscle retraining is a treatment that helps patients to strengthen
or relax their pelvic floor muscles in order to improve bowel or bladder function and
decrease some types of pelvic floor pain.
• Types of biofeedback
– Electromyograph (EMG)
– Surface EMG (SEMG)
– Perineometer
– Vaginal Weights/ Cones
• EMG/ SEMG • An electromyograph (EMG) uses surface
electrodes to detect muscle action potentials from
underlying skeletal muscles that initiate muscle
contraction.
• tool for real-time evaluation of pelvic floor muscle (PFM)
contractions
• Clinicians recorded the surface electromyogram (SEMG)
using one or more target muscles and a reference electrode
that is placed within six inches of either active electrodes.
• Perineometer The perineometer is inserted into the vagina
to monitor PFM contraction and can be used to enhance
the effectiveness of Kegel exercises
• Cones are inserted into the vagina and the pelvic floor is contracted to prevent
them from slipping out.
 VAGINAL PESSARY
• A pessary trial is a low risk option for women experiencing symptomatic POP.
• should be considered and offered routinely.
• Most patients 73-92% can be successfully fitted with a pessary and rates of continued pessary range
from 16-89% at the end of 1 year.
• Old age >65 years is the greatest predictor of continued use.
• Pessaries may prevent progression of a prolapse or result in improvement in the severity (Shah et al
2006).
• One study reported improvement in POP-Q stage in all women after one to four years of pessary use,
with no deterioration in the stage of prolapse reported in any of the women (Handa & Jones 2002).
• Change in genital hiatus size after three months of pessary use has been observed. There was a
decrease in hiatus size from 4.8cm to 4.1 cm at two weeks after fitting and a further decrease to 3.9cm
at three months. Changes were most marked with the Gellhorn pessary (Jones et al 2008).
 INDICATIONS OF PESSARY

• Primary therapy

• Medically unfit for surgery

• Preference for non-surgical management

• Diagnosis & preoperative evaluation

• Occult incontinence, urinary retention & pelvic pain should be evaluated

• Temporary treatment of prolapse symptoms

• Younger women till childbearing is completed

• Healing of vulvar erosions secondary to large prolapse

• Interim measure while patient prepares for surgery

• Urinary incontinence

• Alternative to surgery for SUI

Obstetric indications : incompetent cervix

 CONTRAINDICATIONS OF PESSARY USE

• Allergy to product
• Chronic vaginal irritation, erosions or ulcerations, PID
• Active infection
• Non-compliant patients
• Unable to present for periodic examination
• Marked vaginal atrophy – “prepare” vagina with estorgen cream.
• Medical disorders like dementia
• Endometriosis has been suggested as a possible contraindication to pessary use
FACTORS ASSOCIATED WITH FAILURE OF LONG TERM PESSARY
USE

• Short vagina <6 cm

• Wide introitus > 4 finger breadths
• Previous hysterectomy
• Previous reconstructive surgery
• Stress urinary incontinence
TYPES OF PESSARIES
 TYPES OF PESSARIES

SUPPORT SPACE FILLING

Use a spring-like mechanism; rests Maintain position by creating

in the posterior fornix and against suction between the pessary and
the posterior aspect of the pubic the vaginal walls (cube), by
symphysis. Vaginal support results providing a larger diameter than
from elevation of the superior the genital hiatus (donut), or by
vagina by the “spring.” both mechanisms (Gellhorn).
 TYPES OF PESSARIES
SPACE
SUPPORT FILLING

A) Ring
b) Shaatz
(E) Ring with support
(G) Risser (C) Gellhorn

(H) Smith (D) Gellhorn

(K) Hodge with knob
(F) Gellhorn
(L) Hodge
(I) Tandem cube
(M) Gehrung
(N) Incontinence dish with (J) Cube
support
(O) Donut
(P) Incontinence ring
(Q) Incontinence dish (S) Inflatoball (latex).

(R) Hodge with support

• Cystoceles / SUI – ring or lever (smith-Hodge) pessaries
• Stage II apical (middle) compartment defects (uterine,vaginal vault, enterocele) – ring
pessaries
• Stage III or IV uterine or vaginal vault prolapse – Gellhorn or donut pessaries
• Rectocele – donut pessaries
• Wide genital hiatus – space-filling pessary
• Patient removing & reinserting the pessary – ring pessary
 RING PESSARY
• Ring pessary is the commonly used support pessary.
• Preferred for stage 1-2 prolapse.
• Easy insertion and removal
• Some have been designed specifically to treat SUI like incontinence dish and ring pessary with
knob.

Ring with support Ring with knob Incontinence dish

 GEHRUNG AND REGULA PESSARY

• Support type
• has wires that allow it to be manually shaped for different anatomies
• Cystoceles, rectoceles, II or III degree uterine prolapse
• Must be removed during x-rays, ultrasounds and MRI .
Gehrung pessary

Regula pessary
 HODGE PESSARY
• They are designed to support the urethra and provide gentle compression of
the urethra against the pubic bone.
• This structural arrangement reduces and often prevents leakage when intra-
abdominal pressure increases.
• An incontinence pessary supports the urethrovesical junction in the same
way a vaginal sling implanted surgically would.
 GELLHORN PESSARY
• Gellhorn pessary is the commonly used space filling pessary. Preferred for
stage 3-4 prolapse
• Pessary has a wide base and either a long or short stem
• The base creates suction onto the vaginal walls so that it stays in place
without relying on the symphysis to keep it in place
• The cervix rests in the concave upper surface of the base, while the knob at
the end of the stem rests on the posterior vaginal wall and perineal body
• Must be removed for intercourse, which makes them less suitable for
sexually active women
 CUBE PESSARY

• The concave surfaces provide suction onto the vaginal walls to hold it in place
• Must be removed for intercourse .
• Should be removed nightly (Bash 2000) .
• It may be difficult to insert and remove.
• More chances of vaginal ulcerations and heavy discharge.
• Used in stage 3/4 prolapse.
 DONUT PESSARY AND INFLATOBALL

• For effective support in second- or third-degree prolapse.

• The inflatoball is effective in patients with a mild cystocele or
inflatoball
rectocele associated with a procidentia/prolapse.
• support can be adjusted based on the inflation level of the
pessary.
• The inflatoball pessary is made of latex rubber and should not be
left in place more than 24 consecutive hours.
• Donut pessaries are effective in women with wide introitus.
Donut
 HOW TO INSERT A PESSARY

• Advise woman to arrive with her rectum empty.

• Have her void immediately prior to fitting
• Reinforce the “trial & error” nature of pessary fitting
• Allow woman to examine and hold pessary prior to insertion
• Inform that fitting process itself maybe a little uncomfortable
• fully inform about the benefits, risks, need for long term follow-up, and be an active participant
in the process be shown the pessary and allowed to handle and bend it
• show how it will sit in the body using pelvic diagrams or models
• informed consent
• Insert two fingers into the vagina

• Extend fingers to either side of the vaginal fornices

• Keep fingers extended and pull through introitus

• If you must close your fingers to get them out a pessary will
probably be retained

• Insert first two fingers of dominant hand deep to the posterior Pessary sample kit

fornix

• Approximate size by using the fingers to determine the width

• Spread fingers wide to measure

• Remove fingers and compare to pessary sample or fitting kit

• Mix Xylocaine gel (50-50) with lubricant
• Avoid lubricating the pessary itself
• Generously lubricate the vaginal introitus with non-dominant hand
• Grasp pessary with the non-lubricated hand in order to keep a firm hold
• As an alternative may lubricate the leading edge of the pessary
• Fold the pessary in between the two fingers and thumb and keeping its long
axis towards perineum gently insert it high up in posterior fornix

• Direct its anterior rim towards anterior vaginal wall so that it hinges behind
pubic symphysis.
 ENSURE A SUCCESSFUL FIT!

• Pessary is comfortably retained during upright, walking, squatting, valsalva and coughing
• Pessary is not felt by the woman and does not cause any pain or discomfort
• Pessary does not obstruct bladder or bowel emptying
• Therefore it is important to ask the patient to walk around, squat, cough and urinate post insertion
in OPD itself.
REMOVAL OF PESSARY

• Ring pessaries - foldable , easy to insert and remove. Removed every two to three days , washed
with water and re-inserted.
• Cube pessaries- Suction of cube pessaries needs to be broken before removal by putting your
fingers and thumb between the cube pessary and the vaginal walls
.Ease the pessary out. NEVER PULL ON THE STRING OR SILICONE TAIL
this may tear the vaginal mucus membrane. They should be removed and reinserted
daily.(Bash et al ,2000)
• Gellhorn pessary- Suction needs to be broken before removal.
 PESSARY CARE

• Self-care consists of periodic removal of the pessary for cleaning and replacement.
• Patient / care giver should be taught about removal , reinsertion. Ideally ,the pessary to
be removed each night, washed with soap water, and reinserted in the morning .
• Atrophic vaginitis is to be treated with estrogen application .
• Self-care should be individualised (Atnip 2009).
• Manufacturer’s instructions should be followed
 FOLLOW UP
FIRST FOLLOW UP
Individualized. Need to return within 1-3 days of pessary fitting
Return earlier:
• Should pessary become uncomfortable
• If urination or a bowel movement is difficult
• If pessary falls out or becomes displaced

SUBSEQUENT VISITS
• Return in one month, and gradually lengthen to every 2 to 3 months
• Instruct the woman to return earlier if any odor, discomfort, or abnormal discharge
• Reinforce that proper follow-up is important since most women have limited sensation in the vagina and may not
be physically aware of any ulcerations
• A list should be kept of pessary users and their expected date of return
 COMPLICATIONS OF PESSARY

• Vaginal bleeding (44%)

• Extrusion (26%)
• Vaginal discharge (24%)
• pain (24%)
• Erosion
• Severe vaginal discharge associated with infection e.g. bacterial vaginosis
• Cervical incarceration (by a ring pessary)
• Impacted embedded pessaries , causing vesicovaginal or rectovaginal fistulae
 TREATMENT OF COMPLICATIONS

• Vaginal discharge and odour : douche with warm water, nightly replacement of pessary, patient can
also use a ph balanced oxyquinoline gel 1-3 times a week (Trimo San gel)
• Pre-treatment with topical oestrogen cream such as Premarin cream 1gm daily for 2 weeks , then twice
weekly thereafter to treat atrophic vaginitis can decrease the incidence of vaginal bleeding and erosions
caused by pessary.
• Expulsion, pelvic pain and leaking or obstruction of urine can occur due to a faulty pessary size and
needs revaluation.
• Decubitus ulcer: is treated by keeping the prolapse reduced, which will restore circulation and help in
healing. Prolapse can be kept in reduced position by packing. Hygroscopic agents such as acriflavine-
glycerine can be used to reduce the congestion furtherCan leave a hyperpigmented patch post healing
CASE DISCUSSION
CASE:

45 year old, perimenopausal P5L3 female presented to the gynae OPD with
complain of something coming out of vagina for past 1 year which increased
progressively to the present size
• The mass increases in size on coughing , straining, lifting heavy weight
• The mass does not reduce spontaneously on lying down and has to be
manually reduced and was associated with heaviness, feeling of pressure
and difficulty in walking.
• No history of any ulceration or discharge .
• Patient manually reduces the mass to start passing urine. No history of
increased frequency , urgency, difficulty in micturition, hesitation
incomplete micturition and presence of stress incontinence.
• No history of constipation or feeling of incomplete evacuation.
• No h/o post coital bleeding or dyspareunia
• No h/o backache
Past history :
Medical- no h/o chronic cough, asthma/COPD , chronic constipation.
Surgical- no h/o previous surgery

O/H: P5L3, all normal vaginal deliveries ( home deliveries supervised by

dai) all with inter conceptional interval of 1-2 yrs. No history of
big size baby, prolonged labour, instrumental delivery.

M/H: Perimenopausal; patient was having regular menstrual cycles till about 6
months ago; now having prolonged cycles once in 2-3 months

Family history: No h/o of prolapse or hernia in any family members

Personal history: worked as labourer since last 5 years . No history of smoking.

Pelvic floor distress inventory
1. 2
2. 2
3. 4
4. 1
5. 1
6. 4
SCALE SCORE : 58.3 out of 100

1. 1
2. 1
3. 1
4. 1
5. 1
6. 1
7. 1
8. 1
SCALE SCORE : 25 out of 100

1. 1
2. 1
3. 1
4. 1
5. 1
6. 2
7. 2
8. 1
SCALE SCORE : 31.25 out of 100

SUMMARY SCORE : 114.55 out of 300

BLADDER OR URINE
1. Mild
2. None
3. None
4. None
5. Mild
6. Mild
7. mild

SCALE SCORE : 19.04 out of 100

BOWEL OR RECTUM
8. None
9. None
10. None
11. None
12. None
13. None
14. None

SCALE SCORE : 0 out of 100

VAGINA OR PELVIS
15. Mild
16. Mod
17. Mild
18. mild
19. Mild
20. Mild
21. Mild

SCALE SCORE : 38.09

SUMMARY SCORE : 57.13 out of 300

General physical examination:
Conscious, oriented
Built-thin built
Height: 168cms
Weight: 45kgs
BMI: 17.6 kg/m2
Pallor absent
BP:110/76 mmhg
PR:84/min
Gait normal
Spine normal
B/l breast soft, no lump palpable, no nipple discharge

Systemic examination:
Respiratory: b/l chest clear, b/l air entry +, no added sound
CVS: S1S2 +, no murmur
GI: no organomegaly
P/A: abdominal wall lax, no previous surgery scars, no lump
palpable, no organomegaly, hernia sites normal

L/E in dorsal supine position without emptying bladder

Wide gaping introitus

Vulva- healthy

Vagina- no atrophic changes

Vaginal epithelium healthy , vaginal rugosities present , no
decubitus ulcer seen . No pigmentation

Bulbo cavernosus reflex +, anal wink reflex +

No SUI demonstrated with prolapse outside and reduced.

Anterior compartment examination:
Bulging of the anterior wall noted
Central vaginal rugosities maintained
Blunting and descent of lateral sulci noted
On supporting lateral sulci with ring forceps, there was decrease in bulge of anterior vaginal
wall
s/o anterior compartment prolapse with lateral defect

Apical compartment examination: On straining, entire cervix is visualized outside the

introitus s/o apical compartment prolapse
No congestion/ hypertrophy/decubitus ulcer noted

Posterior compartment examination: On retracting posterior speculum, bulge noted in upper

part and lower part of posterior vaginal wall s/o posterior compartment prolapse
P/V: uterus normal size, anteverted
B/L fornices free / Non tender .

Levator tone (OXFORD SCALE) 2/5 .

Pelvic floor muscle assessment. The index

finger is placed 2 to 3 cm inside the hymen at
4 and 8 o’clock. Both resting and contraction
tone and strength are evaluated
POP Q
Aa Ba C
+3 +5 +8

GH PB TVL
4.5 2.5 8

Ap Bp D
0 +4 -2

POP Q stage IV , lithotomy with straining with cervix leading edge

PROVISIONAL DIAGNOSIS:

45 year old perimenopausal P5L3 with Stage IV multicompartment pelvic organ

prolapse with cervix leading edge
without SUI without decubitus ulcer